BACKGROUND:The Australian alcohol health guidelines were revised in 2020 to recommend a maximum of 10 drinks/week. We calculated estimates of cancer caused by alcohol use in Australia for the updated recommended limits. METHODS:Cox regression models were used to estimate hazard ratios (HR) for cancer incidence in relation to self-reported alcohol consumption (drinks/week) among 225,805 participants aged ≥45 years (2005-2009) in the New South Wales (NSW) 45 and Up Study, an Australian prospective cohort study (baseline n = 267,357). Cumulative absolute risk of cancer to age 85 years was estimated using 0 to <1 drink/week as the comparator. Population attributable fractions were calculated using Australian national alcohol consumption and cancer incidence data, compared to a theoretical minimum risk exposure of no alcohol consumption. Cancer cases and deaths were ascertained through record linkage to the NSW Cancer Registry and NSW Registry of Births Deaths & Marriages to 2019. Participants diagnosed with cancer pre-baseline were excluded. RESULTS:Over a median 11.4 years, 34,860 cancer cases were recorded. When modelled as a continuous variable, alcohol-related cancer risk increased by 19% for every ten drinks/week increase in consumption (HR: 1.19; 95% confidence interval: 1.15-1.23). By age 85 years, those who consumed >10 drinks/week had an estimated 4.9% higher cumulative absolute risk of an alcohol-related cancer compared to those consuming 0 to <1 drink/week. An estimated 7804 cancer cases (4.6% of all cancer cases) were attributable to alcohol use in 2024. CONCLUSIONS:The proportion of alcohol-attributable cancers in Australia is substantial and somewhat higher than previously estimated.

Abstract Background Since July 2022, Australian National Cervical Screening Guidelines have recommended anyone eligible for cervical screening be offered the choice between having their sample collected by a clinician with a speculum, or self-collection using a vaginal swab. Method We recruited screen-eligible people to an online survey between December 2023 and April 2024, via a paid social media (Meta) campaign, and stakeholder and community networks. Using binary logistic regression, we assessed demographic and screening history factors associated with having previously heard of self-collection. In participants screened since July-2022, we assessed factors associated with being offered a choice between self-collection and clinician-collection; choosing self-collection (among those offered choice); and using self-collection (among all recently screened participants). Results Of the 9,928 participants, 70.2% had heard of self-collection. Among those screened since July 2022, 36.1% were offered a choice in screening method. Awareness was associated with increasing age (p-trend <0.001 ), with participants aged >65 years most likely to have heard of self-collection (adjusted odds ratio (aOR): 1.69, 95% confidence interval (95%CI): 1.31-2.18). Compared to participants who self-reported regularly attending cervical screening, both not-regular and never screeners (based on self-reported screening history, frequency, age and sexual history) were less likely to have heard of self-collection (aOR:0.80 [95%CI:0.72-0.89] and aOR:0.73 [95%CI:0.56-0.96], respectively; p <0.001 ). Participants who attended a specialised women’s/sexual health clinic were more likely to have heard of self-collection (aOR:1.32 (95%CI:1.06-1.64), p; <0.001 ), and to report being offered choice (aOR:1.62 (95%CI 1.22-2.14), p <0.001 ) at their last cervical screen. Half of the participants who were offered a choice opted for self-collection (N=803/1,617; 49.7%). Not-regular screeners were twice as likely (aOR:2.31 (95%CI:1.74-3.07), p <0.001 ) to choose self-collection as regular-screeners. Conclusion Given almost 50% of women nationally are now choosing self-collection, these findings imply national uptake might be close to plateauing overall. In high income settings where a choice in screening methods is introduced with the aim of improving screening equity, resources, adequate training, and health promotion tools should be provided prior to program launch to support healthcare providers in offering choice and facilitate improved participation in screening programs. Raising community awareness of screening options is important and needs to reach under-screened groups.

INTRODUCTION:To explicitly assess the impact of theory in implementation strategies, it is essential to isolate theoretical components while controlling other variables. AIM:This exploratory two-arm cluster-randomized implementation trial compared theory-driven versus intuition-based approaches to the development of strategies to improve risk-appropriate tumor testing and referral to genetics services for Lynch syndrome (LS), a hereditary cancer predisposition condition. METHODS:Seven major Australian hospitals received an identical, seven-step implementation approach, with the only difference being either the use of theory-driven or intuition-based implementation strategy development, which was randomly assigned (theory n = 4; intuition n = 3). The theory-driven approach was guided by the Theoretical Domains Framework (step 4) and matched Behavior Change Techniques (step 5), with all other steps identical between both trial arms. The primary outcome was the rate of risk-appropriate LS tumor testing and referral within 2 months of colorectal cancer (CRC) resection, using data from January 1, 2017 to September 30, 2021 (n = 3,321 patients). Secondary outcomes included the proportion of risk-appropriate patients with a genetic referral. RESULTS:The theory-driven arm showed a modest but non-significant improvement in the primary outcome of risk-appropriate LS pathway completion (adjusted risk ratio [aRR]=1.22, 95% CI: 0.92- 1.61, p  = 0.1713); however, this was driven by one large hospital, with null effect when excluding that hospital (aRR = 1.00, 95% CI: 0.86-1.18, p  = 0.9639) and heterogeneous results across different hospitals. For patients with high LS risk tumor test results, the theory-driven arm showed a significantly lower proportion without a genetics referral (secondary outcome: aRR = 0.50, 95% CI: 0.41-0.61, p  < 0.0001). CONCLUSION:Theory-driven implementation led to stronger improvements in a secondary outcome. Primary outcome evidence was inconclusive. While theory-driven approaches led to some improvements in a secondary outcome, there was no conclusive difference in the primary outcome. A published process evaluation reports on the contextual factors influencing results at each site, as well as theoretical alignment of intuitive strategies and their proposed mechanisms of action. This trial design offers a template for isolating and evaluating the contribution of theory to implementation strategies. TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry, ACTRN12618001072202. Registered June 27, 2018 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375348&isReview=true. SPANISH ABSTRACT:http://links.lww.com/IJEBH/A491.

Background:New Zealand experienced a prolonged period of minimal regulation on e-cigarettes until the passing of the 2020 Smokefree Environments and Regulated Products (Vaping) Amendment Act. Methods:Interrupted time series analyses of the Action for Smokefree 2025 (ASH) Year 10 Snapshot Survey data from 1999 to 2023 to compare changes in smoking trends among 14-15-year-old students (n = 690,470) before and after the advent of vaping in New Zealand (around 2010). Findings:The prevalence of daily-vaping increased from 1.1% in 2015 (the first year the question was asked) to 1.8% in 2018 before rising to 10.0% in 2023, a nine-fold increase over eight years. From 1999 to 2023, considerable declines in ever-, regular-, and daily-smoking prevalence were observed. However, the rates of decline in ever- and regular-smoking slowed significantly from 2010 onwards (p < 0.001 for both), coinciding with the advent and rapid growth of vaping among New Zealand adolescents. In contrast, the rate of decline in daily-smoking did not significantly change from 2010 onwards (p = 0.066). These findings were robust to sensitivity analyses, including the use of different time series interruption points (change-years) and controlling for inflation-adjusted cigarette prices. Interpretation:Our findings starkly contrast with those from a previous analysis of ASH data, which suggested that e-cigarettes appear to be displacing smoking among New Zealand youth. Instead, our findings suggest that among 14-15-year-olds, the rapid rise of vaping may have slowed the rates of decline in ever- and regular-smoking, while having little or no impact on the rate of decline in daily smoking. Our findings underscore the importance of effective policy approaches to curb both adolescent vaping and smoking. Funding:None.

The increasing prevalence of e-cigarette use (vaping) among adolescents and young adults has ignited debate over its potential role in the initiation of cigarette smoking. Prospective cohort studies at the individual level consistently demonstrate a higher risk of smoking initiation among young people who have previously vaped when compared with those who have never vaped (sometimes called a 'gateway effect'). On the other hand, several studies analysing repeated cross-sectional data argue that vaping might decrease the risk of smoking through a 'displacement effect', as evidenced by an increasing vaping trend coinciding with a decreasing smoking trend. This perspective article examines these conflicting viewpoints in the context of a misinterpretation of these coinciding trends.

Objectives: Although schools have an important role to play in preventing vape use, literature about teacher perceptions of vaping among students is limited. This study investigated teachers' perceptions of student vaping in Australian secondary schools over a 12-month period.Design: Mixed methods design.Setting: Australian secondary schools.Method: We used quantitative survey data from secondary school teachers for three waves of the Generation Vape project from March-April 2022 to March-April 2023 (n = 1,364), and qualitative focus group data from March-April 2023 (n = 6 groups, n = 32 participants). Differences in survey data across time were tested using multinomial regression and linear regression, and common focus group data themes were identified.Results: Eighty-five percent of teachers were concerned or very concerned about vaping at school, with the proportion who were very concerned increasing from 43% to 55% over the 12 months. There was consistent and strong agreement that vape use is unsafe for young people and high agreement that vaping during adolescence can cause addiction. Focus group discussions provided context to survey findings: teachers' awareness of and concern about vaping in schools, and the harms of vaping in students, which both then influenced school priorities for vaping management. Findings suggest inconsistent strategies to manage vaping in schools detract teachers from their core focus on teaching.Conclusion: Our study, the first to investigate teacher perceptions of vaping in Australian secondary schools across time, demonstrates increasing teacher concerns. As vaping is a community-wide problem, a coordinated response across government is required to support teachers in reducing student vape use at school.

OBJECTIVE:To compare adolescent smoking trends in Australia before and after the emergence of e-cigarettes in about 2010, to evaluate the potential impacts of adolescent vaping on smoking prevalence. DESIGN:Repeated cross-sectional study. SETTING:Australian secondary schools. PARTICIPANTS:172 406 students aged 12-17 years who took part in the Australian Secondary Students' Alcohol and Drug Survey between 1999 and 2023. MAIN OUTCOME MEASURES:Prevalence of ever, past year, past month and past week smoking for 12-17-year-olds, and daily smoking for 14-15-year-olds. RESULTS:From 2014 to 2022-2023, the prevalence of ever vaping among students increased 2.3-fold (from 13.2% to 29.9%), while past month vaping increased 4.8-fold (from 3.3% to 15.7%). From 1999 to 2022-2023, there were substantial declines in the prevalence of ever, past year, past month, past week and daily smoking among students, with reductions ranging between 74% and 89%. However, the rates of decline for these five measures of smoking slowed significantly from 2010 onwards, coinciding with the emergence of vaping. By 2022-2023, there were, respectively, 74 (95% confidence interval [CI], 67-80), 54 (95% CI, 48-60), 25 (95% CI, 21-29) and 16 (95% CI, 12-19) more 12-17-year-olds per 1000, and 7 (95% CI, 4-9) more 14-15-year-olds per 1000 who had engaged in ever, past year, past month, past week and daily smoking than projected by smoking trajectories from the pre-vaping era. These findings were robust to sensitivity analyses, including the use of different time series interruption points (change-years) and controlling for the affordability of cigarettes. CONCLUSION:Australia's remarkable progress in reducing adolescent smoking has slowed since the emergence of vaping, underscoring the need for integrated tobacco and vaping control strategies.

The coronavirus disease 2019 pandemic substantially impacted the delivery of cancer services and programs. Here we reviewed and synthesized the global scale and impact of pandemic-related delays and disruptions on cancer services, including diagnosis, diagnostic procedures, screening, treatment and supportive and palliative care. Based on data from 245 articles in 46 countries, we observed declines in the number of cancer screening participation (39.0%), diagnoses (23.0%), diagnostic procedures (24.0%) and treatment (28.0%), ranging from a 15.0% decline for radiotherapy to a 35.0% decline for systemic treatment during the pandemic compared to during the prepandemic period. Medium-human development index (HDI) category countries experienced greater reductions than high- and very-high-HDI countries. Missing data from low-HDI countries emphasize the need for increased investments in cancer surveillance and research in these settings. PROSPERO registration: CRD42022301816.

Background:Ethnic inequities in health and mortality in Aotearoa/New Zealand have been driven in part by historic and ongoing inequities in smoking prevalence, with Māori and Pacific peoples most affected. Although overall smoking rates among year 10 students aged 14-15 years have declined substantially in recent decades, recent analyses suggested that e-cigarette use (vaping) may have slowed the decline in ever- and regular-smoking, while having little or no impact on daily smoking. However, it remains unclear whether these patterns differ for Māori, Pacific, European, or Asian adolescents. Methods:Interrupted time series analyses of the Snapshot Survey data (2003-2024; n = 588,143) to assess changes in smoking trends before and after the emergence of vaping in Aotearoa among 14-15-year-old Māori, Pacific, European, and Asian adolescents. Findings:From 2003 to 2024, ever-, regular-, and daily-smoking prevalence declined substantially among Māori, Pacific, European, and Asian adolescents. However, the rates of decline in ever-smoking slowed significantly from 2010 onwards-coinciding with the emergence of vaping in Aotearoa-for Māori (p = 0.025), European (p < 0.001), and Asian (p = 0.018) adolescents. Similarly, declines in regular-smoking slowed significantly for Māori (p = 0.012), Pacific (p = 0.003), and European (p < 0.001) adolescents. A significant change in the rate of decline in daily smoking was observed only for European adolescents, who showed a small slowing (p = 0.004). Findings were robust to different time series interruption-points (change-years) and controlling for cigarette affordability. Interpretation:We found no evidence that vaping is displacing adolescent smoking among any of the four ethnic groups analysed. On the contrary, our findings suggest that the emergence and rise of vaping in Aotearoa may have undermined progress in reducing regular-smoking among Māori, Pacific, and European adolescents, but with more serious implications for Māori and Pacific youth. Funding:None.

Objectives: Despite relatively high alcohol consumption in Australia, local evidence regarding drinking and causespecific mortality is limited. We aimed to quantify the risk of alcohol-related causes of death and to calculate contemporary estimates of absolute risk and population attributable fractions for deaths caused by alcohol consumption in Australia. Study design: Prospective cohort study. Methods: Cox proportional hazards regressions were used to calculate hazard ratios (HR) for cause-specific mortality in relation to overall alcohol consumption and pattern of drinking among 181,607 of 267,357 participants aged >= 45 years (2005-2009) in the New South Wales 45 and Up Study, with linkage to death records to December 24, 2019. Cumulative absolute risks and population attributable fractions were estimated. Results: Over a median 11.4 years, there were 18,193 deaths. Every additional seven drinks/week increased risk of death from: alcohol-related cancers combined by 12 % (HR = 1.12; 95%CI = 1.05-1.18); digestive system disease by 32 % (1.33; 1.22-1.44); falls by 23 % (1.23; 1.03-1.46); cardiovascular disease by 7 % (1.07; 1.03-1.11); alcohol-related causes combined by 10 % (1.10; 1.07-1.12); and from all-cause mortality by 6 % (1.06; 1.04-1.08). By age 85 years, men and women who consumed >10 drinks/week were estimated to have 8.5 % and 4.1 % higher cumulative absolute risk of mortality from alcohol-related causes, respectively, compared to those consuming 0 to <1 drink/week. An estimated 9029 deaths (5.3 % of all deaths) were attributable to alcohol consumption in Australia in 2021. Conclusions: Excess risk of death from alcohol consumption in Australia is substantial. Given relatively high alcohol intake, interventions aimed at reducing consumption may translate into significant public health gains.

Abstract Background Tobacco industry activities and reduced smoking prevalence can foster under-appreciation of risks and under-investment in tobacco control. Reliable evidence on contemporary smoking impacts, including cause-specific mortality and attributable deaths, remains critical. Methods Prospective study of 178,169 cancer- and cardiovascular-disease-free individuals aged ≥ 45 years joining the 45 and Up Study in 2005–2009, with linked questionnaire, hospitalisation, cancer registry and death data to November 2017. Cause-specific mortality hazard ratios (HR) by smoking status, intensity and recency were estimated, adjusted for potential confounding factors. Population attributable fractions were estimated. Results There were 13,608 deaths during 9.3 years median follow-up (1.68 M person-years); at baseline, 7.9% of participants currently and 33.6% formerly smoked. Mortality was elevated with current versus never smoking for virtually all causes, including chronic lung disease (HR = 36.32, 95%CI = 26.18–50.40), lung cancer (17.85, 14.38–22.17) and oro-pharyngeal cancers (7.86, 4.11–15.02); lower respiratory infection, peripheral vascular disease, oesophageal cancer, liver cancer and cancer of unknown primary (risk 3–5 times as high); and coronary heart disease, cerebrovascular disease and cancers of urinary tract, pancreas, kidney, stomach and prostate (risk at least two-fold); former versus never-smoking demonstrated similar patterns with attenuated risks. Mortality increased with smoking intensity, remaining appreciable for 1–14 cigarettes/day (e.g. lung cancer HR = 13.00, 95%CI = 9.50–17.80). Excess smoking-related mortality was largely avoided with cessation aged < 45 years. In 2019, 24,285 deaths (one-in-every-six deaths, 15.3%), among Australians aged ≥ 45 years, were attributable to tobacco smoking. Conclusions Smoking continues to cause a substantial proportion of deaths in low-prevalence settings, including Australia, highlighting the importance of accelerated tobacco control.

PURPOSE:Surgery remains the primary treatment for early-stage colorectal and upper gastrointestinal (UGI) cancers. However, it can lead to postoperative complications and reduced functionality. Prehabilitation aims to improve functional reserves before surgery. We aimed to evaluate the implementation of a multimodal prehabilitation program in "real-world" patients undergoing gastrointestinal cancer surgery. METHODS:An implementation study evaluating prehabilitation in patients undergoing gastrointestinal (colorectal or UGI) cancer surgery at Concord Hospital. The prehabilitation program included supervised exercise, nutrition and nursing support delivered face-to-face or by telehealth (COVID-19 adaptations). ASSESSMENTS:baseline, pre-surgery and 30 days after surgery. PRIMARY OUTCOME:implementation using the RE-AIM (Reach/Effectiveness/Adoption/Implementation/Maintenance) framework. SECONDARY OUTCOMES:functional, nutritional and surgical outcomes, with comparisons to historical controls. RESULTS:Between January 2020 and December 2021, 181 patients were screened; 91 (50%) were eligible. Reach: 77/91 recruited (63 colorectal, 14 UGI). Median age, 70 years (IQR, 59-79); 60% were males. Median intervention duration, 16 days (IQR, 12.25-19.75). EFFECTIVENESS:quality of life, anxiety and functional capacity improved from baseline to pre-surgery (6-min walk test (+16.1 m, p=0.038) and 2-min step test (+10.0 steps, p<0.001)). Compared to historical controls, hospital length of stay was reduced by 2.1 days (p=0.010), with no differences in complications. Adoption: 91% of referrals came directly from surgeons. IMPLEMENTATION:94% completed the intervention, with high adherence and satisfaction levels. Maintenance: after study completion, the program was incorporated into standard care with some modifications. CONCLUSIONS:Prehabilitation can be implemented in a real-world setting, with a trend towards improving functional and surgical outcomes, but dedicated resources are necessary to implement and maintain the program.